If any activities above are checked, please list where, when, and level of experience:

Parent/Guardian Information

Name
*

First Name Last Name

Relationship
*

Name
*

First Name Last Name

Relationship
*

Address
*

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Home Number
*

-
Area Code Phone Number

Cell Number
*

-
Area Code Phone Number

E-mail
*

example@example.com

Emergency Information

Emergency Contact's Name
*

First Name Last Name

Relationship
*

Phone Number
*

-
Area Code Phone Number

Alt. Phone Number

-
Area Code Phone Number

Primary Physician's Name

First Name Last Name

Phone Number

-
Area Code Phone Number

How did you hear about CirqueFit® Summer Camps?
*

Someone Somewhere (website, advertisement, etc.) Other

Who referred you?
*

First Name Last Name

What was the website, advertisement, or other way that you heard about CirqueFit® Summer Camps?
*

Camp Sessions

Please select the session(s) you would like you students(s) to attend. Also, please be sure to select the number of students you are enrolling in each session selected.

Select the CirqueFit® camp(s) you'd like your children to attend
*

Session 1 ~ HALF DAY 9:00 am - 12:00 pm ~ JUNE 4 - 8, 2018
$
275

Number of students you're enrolling in this camp

Session 1 ~ FULL DAY 9:00 am - 4:00 pm ~ JUNE 4 - 8, 2018
$
395

Number of students you're enrolling in this camp

Session 2 ~ HALF DAY 9:00 am - 12:00 pm ~ JULY 9 - 13, 2018
$
275

Number of students you're enrolling in this camp

Session 2 ~ FULL DAY 9:00 am - 4:00 pm ~ JULY 9 - 13, 2018
$
395

Number of students you're enrolling in this camp

Session 3 ~ HALF DAY 9:00 am - 12:00 pm ~ JULY 23 - 27, 2018
$
275

Number of students you're enrolling in this camp

Session 3 ~ FULL DAY 9:00am - 4:00pm ~ JULY 23 - 27, 2018
$
395

Number of students you're enrolling in this camp

Total:
$
0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Date

Postal Code

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Illumine Arts LLC (DBA Dallas Cirque Theatre, DBA CirqueFit). I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Illumine Arts LLC (DBA Dallas Cirque Theatre, DBA CirqueFit) and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from activities at Illumine Arts LLC (DBA Dallas Cirque Theatre, DBA CirqueFit).

In case of injury to said child, I hereby waive all claims against Illumine Arts LLC (DBA Dallas Cirque Theatre, DBA CirqueFit) including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including circus arts. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Illumine Arts LLC (DBA Dallas Cirque Theatre, DBA CirqueFit) and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.